patient information - my neighborhood primary care€¦ · medication administration, infusions,...

Name: _______________________________________ Date of Birth: ________________________________________

Race: Native American, Eskimo Asian/Pacifier Islander Black Multi-Racial White Other Unknown

Ethnicity: Hispanic Non-Hispanic Unknown Other Interpreter Needed Yes No

Mailing Address: _______________________________________________ City: _________________________________

State: _______________________________ Zip Code:______________________________________________________

Social Security Number: _____________________ Email Address: ____________________________________________

Home Phone:___________________________________ Cell Phone:__________________________________________

EMPLOYMENT

Employment Status: Full Time Part-time Not Employed Self-Employed Retired Other _________________

If Applicable, Employer Name: ___________________________________________________________________________

Student Status: Full-time Part-time Not a Student

INSURANCE

Primary Insurance Name of Insurance: ________________________________________________

Subscriber's Name, if different: _______________________Subscriber's SSN: __________________________________

Subscriber's Birth Date: _________________ ID#:_________________________ Group #:_______________________

Patient's Relationship to subscriber: Self Spouse Child Other

Secondary Insurance (If applicable) Name of Insurance: ________________________________________________

Subscriber's Name, if different: _______________________Subscriber's SSN: __________________________________

Subscriber's Birth Date: _________________ ID#:_________________________ Group #:_______________________

Patient's Relationship to subscriber: Self Spouse Child Other

EMERGENCY CONTACT

Name of Emergency contact person: _______________________________ Relationship to Patient: ________________

Home Phone Number:________________ Work Phone Number:___________________________________________

The above information is true to the best of my knowledge. I authorize Arizona Bleeding Disorders Health and Wellness

Center to treat me.

X___________________________________________________________________ _______________________________

Patient/Guardian Date

Patient Information

Medical Treatment Consent:

I (the undersigned, and/or the parent or legal guardian) consent to the administration of reasonable and

necessary services in connection with treatment of the above-mentioned patient at Arizona Bleeding

Disorders Health & Wellness Center. This consent includes, but is not limited to, laboratory procedures,

medication administration, infusions, procedures, and/or services rendered to a patient by members of the

medical staff, their representatives, and/or associates, and employees under the instruction of the physician. I

acknowledge that no guarantees have been made to me as to the results of treatments or examination in the

clinic.

Release of Information and Assignment of Insurance Benefits:

Release of Information: I hereby authorize Arizona Bleeding Disorders Health & Wellness Center and any

physician who has rendered services to release any and all information pertaining to my (or the patient’s)

treatment to enable the collection of benefits for the services rendered. The authorization includes release

of information to insurance companies or healthcare providers, in whole or in part, for payment in exchange

for services rendered, whether such payment is in exchange for services rendered by Arizona Bleeding

Disorders Health & Wellness Center or by the physicians. Release of Information is also authorized to any

providers for follow-up medical care.

Assignment of Benefits: I hereby authorize and assign payment directly to Arizona Bleeding Disorders

Health & Wellness Center for benefits, including secondary benefits, due to me for medical services. I

understand that I am financially responsible for charges not covered by any insurance or medical benefit

payor. I further acknowledge that any benefits, when received by and paid to Arizona Bleeding Disorders

Health & Wellness Center will be credited to my account in accordance with this assignment.

I hereby give permission to receive services and treatment by my physician (and/or associates) at Arizona Bleeding Disorders Health &

Wellness Center. I authorize the release of information including protected health information as needed to file for payment for services

incurred. I fully understand my Financial Responsibility for services rendered at Arizona Bleeding Disorders Health & Wellness Center.

_______________________________________ ____________________________________________ Signature of Patient or Personal Representative Printed Name of Patient or Personal Representative

_______________________________________ ____________________________________________ Date * Relationship to Patient (if Personal Representative)

*If Personal Representative, the patient is unable to sign because (check one):

Other (explain):______________________________________________________________________________________________________________________________

Medical Consent

Acknowledgment of Privacy Practices

& Release of Personal Health

Information / HIPAA

Patient Name: _________________________________________________Date of Birth: _________________

I acknowledge that I have received a copy of the NOTICE OF PRIVACY PRACTICES: _____________ (initials)

I give permission to Arizona Bleeding Disorders Health & Wellness Center to communicate messages regarding

APPOINTMENTS as follows:

______ You may leave a message on my voice mail /answering machine

______ You may leave a message with ____________________________________________________________

______ You may communicate with me through the Patient Portal

______ Please communicate appointment messages as follows: ________________________________________


REFERRALS TO ANOTHER PHYSICIAN as follows:


______ You may leave a message with ___________________________________________________________


______ Please communicate appointment messages as follows: _______________________________________


LAB RESULTS, X-RAYS AND OTHER TESTS as follows:


______ You may leave a message with ___________________________________________________________


______ Please communicate Test Result messages as follows: ________________________________________

Names of individuals who we have permission to release your health information to:

__________________________________________________________________________________________

__________________________________________________________________________________________

Signature of Patient, Parent or Legal Guardian: _______________________________________

Date: ______________________________

PAST MEDICAL HISTORY Please Circle any that apply

Other Medical Conditions (Please List/Explain): __________________________________________________

________________________________________________________________________________________

SURGICAL HISTORY

Type of Surgery Date

Abnormal Pap Smear Emphysema/COPD Hepatitis Seizures

Anemia Enlarged Prostate HIV/AIDS Sickle Cell

Arthritis Glaucoma Irregular Heart Rhythm Skin Problems

Autoimmune Disease Heart Disease Kidney Problems STDs

Blood Clots Heart Attack Liver Disease Stomach Problems

Cancer Heart Failure Lupus Thyroid Problems

Chest Pain Hemophilia Migraines Tuberculosis

Chronic Kidney Disease High Blood Pressure Neck/Back Problems Von Willebrands

Diabetes High Cholesterol Osteoporosis Psychological Disorders

Patient History Form

SOCIAL HISTORY

Marital Status: Single Married Divorced Separated Widowed

Have you ever used tobacco? Yes No Current Use Past Use (Quit ______ Years ago)

If so, which type(s)? _________________________ How many times a day? ___________________

Do you consume Alcohol? Yes No If so, how often? How many drinks per week? ________________

Do you use any recreational Drugs? Yes No Do you have a medical marijuana card? Yes No

REPRODUCTIVE HISTORY for female patients only

Age at first period? ________ Number of pregnancies? ____________ Delivery Types:_________________

____________________________________Last Period: _____________________ Menopausal Status:

Have you ever taken oral contraceptive pills? Yes No _______________________________

Is your flow Regular Irregular How often/Long? _________________________________________

Last Pap: _________________ How many pads/tampons do you use in one day? ___________________

Do you have any pain, bleeding or blood clots? Yes No _______________________________

FAMILY MEDICAL HISTORY

Type of Condition Family Member Age Diagnosed

Arthritis

Asthma

Autoimmune Disease (List Type)

Bleeding Disorder (List Type)

Dementia

Depression

Diabetes Type 1 or Type 2

Heart Disease

High Blood Pressure

High Cholesterol

Kidney Disease

Obesity

Osteoporosis

Stroke

Substance Abuse

Cancer (List Type)

Patient History Form, Cont.

Caffeine Use: Yes No How Much?_____________ Exercise: Yes No How Often?__________

ALLERGIES Please list all known allergies and reactions below

MEDICATIONS Please list all medications

Medication Name Dose Frequency Taken for

Drug Reaction

Name, Address and Number (Phone and Fax)

Local Pharmacy

Mail-in Mail Order Pharmacy

Are you allergic to iodine? Yes No

Are you allergic to latex? Yes No

If you have no known allergies, please circle: No Allergies

Medication & Allergy List

Page 3

Arizona Bleeding Disorders Health & Wellness Center My Neighborhood Primary Care

Please carefully read each statement and sign below. This policy has been put in place to ensure that financial payments due are recovered so that we may continue to provide quality medical care for our patients. It is important that we work together to assure that payment for services is as simple and straightforward as possible. Our staff will be glad to discuss these policies with you.

I understand that if I do not have my insurance card, referral, and/or coh payment that my appointment may be rescheduled until such time that I can provide the required documents or payments.

I understand that reminder appointment calls from the office are a courtesy only, and that I am responsible for keeping track of my appointment and being on time.

I understand I am financially responsible for any co-payments, deductibles, coinsurance and all charges which are not covered by my insurance. I understand that verification of coverage is not a guarantee of payment of benefits. My insurance company determines benefit payments. I understand I will be responsible for the portion not covered by my insurance. If I have an outstanding balance on my account, I agree to pay the balance in full or agree to a payment plan before I am allowed to schedule another appointment. Exceptions are at the sole discretion of the clinic Management.

I understand that if I am unable to make a scheduled appointment I need to contact the office at least 24 hours prior to my scheduled appointment. A $50 FEE MAY BE ASSESSED FOR ALL MISSED APPOINTMENTS NOT CANCELLED WITH AT LEAST 1 BUSINESS DAY WITH A 24 HOUR NOTICE.

I understand there is a $25 charge for a Nonh Sufficient Funds (NSF) check.

I understand there may be a $10h $40 charge for all forms deemed appropriate, filled out by the Physician (e.g. Disability, FMLA, etc.). When dropping forms off, I must allow 5h 7 days for completion.

I understand if my account is not paid in full within 120 days, I may be turned over to a collection agency for further processing and incur an additional 35% fee. Legal action fee will be 50%. In addition, I will be discharged from the practice.

I have read and I understand the above Financial Policy and I agree to abide by its terms

Signature of the Patient or the Patient’s Legal Representative Date

Print Name If not the patient, state your relationship to the patient or describe your authority to act on behalf of the patient

Financial Policy

Page 3Page 3

Arizona Bleeding Disorders Health & Wellness CenterMy Neighborhood Primary Care

821 N 5th Ave Phoenix, AZ 85003 (P) 602-680-7722 (F) 602-682-5415

Medical Records Request and Release Form

Patient Name: DOB: _______________________________

Patient Address: City State Zip Code

I, the undersigned, hereby authorize __________________________________________________

at (F) _________________________________to provide my medical records to the Arizona

Bleeding Disorders Health & Wellness Center/My Neighborhood Primary Care. I understand

that the entire medical record, including information pertaining to drug or alcohol abuse and

psychological or psychiatric treatment, will be provided unless I specify that the following information

should not be released: ___________________________________________________________

Release or transfer of the specified information to any person or entity not specified herein is

prohibited. An additional written consent must be obtained for a proposed new use of the information

or for its transfer to another person or entity.

I understand that I have a right to receive a copy of this authorization upon my request.

Copy requested: Yes No

Patient’s Signature: Date:

or Personal Representative:

Request Received By: Date:

Please Fax the above requested medical records to Arizona Bleeding Disorders Health & Wellness

Center Attn: Jessica Jackson at 602-682-5415.

____ Send all records (complete chart) ____ Send last 5 years____ Send last 1 year

patient information - my neighborhood primary care€¦ · medication administration, infusions,...

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